2014 PQRS Group Practice and ACO GPRO Web Interface ... · CAD-7 / NQF 0066 . Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor

2014 PQRS Group Practice and ACO GPRO Web Interface Reporting Method

GPRO Web Interface Measure Specifications

and Supporting Documents

Training Presentation

Program Year 2014

Disclaimer

This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference.

This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

Disclaimer: If reporting for PQRS through another CMS program (such as the Medicare Shared Savings Program, Comprehensive Primary Care Initiative, or Pioneer ACO Model), please check the program’s requirements for information on how to report quality data to earn a PQRS incentive and/or avoid the PQRS payment adjustment. Please note, although CMS has attempted to align or adopt similar reporting requirements across programs, eligible professionals (EPs) should look to the respective quality program to ensure they satisfy the PQRS, EHR Incentive Program, Value-Based Payment Modifier, etc. requirements of each of these programs.

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Purpose

• This presentation provides information about the GPRO Web Interface for the 2014 program year.

• This presentation is intended for group practices and ACOs submitting data through the GPRO Web Interface.

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Your GPRO Support Team

• CMS – Lisa Lentz, PQRS Lead – Rabia Khan, Shared Savings Program ACO Quality Lead – Terry Ng, Pioneer ACO Model Quality Lead

• QualityNet Help Desk – Monday – Friday: 7:00 am - 7:00 pm CT – E-mail: [email protected] – Phone: (866) 288-8912 (TTY 1-877-715-6222) – Fax: (888) 329-7377

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mailto:[email protected]

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Table of Contents

GPRO Web Interface Measures Overview and Supporting Documents… •6

Care Coordination/Patient Safety (CARE) Module… 14

Coronary Artery Disease (CAD) Composite Module… 22

Diabetes Mellitus (DM) Module (DM-2 and Composite)....... 31

Heart Failure (HF) Module… 46

Hypertension (HTN) Module… 53

Ischemic Vascular Disease (IVD) Module… 57

Preventive Care (PREV) Measures… 64

Resources… 93

GPRO Web Interface

MEASURES OVERVIEW AND SUPPORTING DOCUMENTS

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GPRO Web Interface Measures Overview

• Group practices or ACOs will populate data fields in the GPRO Web Interface (detailed information follows)

• Data fields will cover 22 measures from the following 5 disease modules and 2 patient care modules (individually sampled measures)

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5 Disease Modules

•Coronary Artery Disease (CAD), 1 composite comprised of 2 component measures

•Diabetes Mellitus (DM), 1 individual measure + 1 composite comprised of 5 component measures

•Heart Failure (HF), 1 measure •Hypertension (HTN), 1 measure • Ischemic Vascular Disease (IVD), 2

measures

2 Patient Care Modules (individually sampled measures)

•Care Coordination/Patient Safety (CARE), 2 measures

•Preventive Care (PREV), 8 measures

•Note: The 2 CARE measures and 8 PREV measures are similar to a disease module in that each measure requires completion of the minimum number of patients.

22 Measures via GPRO Web Interface

CMS # / NQF # Title

CARE-1 / NQF 0097 Medication Reconciliation

CARE-2 / NQF 0101 Falls: Screening for Future Fall Risk

CAD-2 / NQF 0074 Coronary Artery Disease (CAD): Lipid Control

CAD-7 / NQF 0066 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)

DM-2 / NQF 0059 Diabetes: Hemoglobin A1c Poor Control

DM-13 / NQF 0729 Diabetes Composite (All or Nothing Scoring): Diabetes Mellitus: High Blood Pressure Control

DM-14 / NQF 0729 Diabetes Composite (All or Nothing Scoring): Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control

The following measures will be available in the GPRO Web Interface for the 2014 program year (1/1/2014 – 12/31/2014):

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22 Measures via GPRO Web Interface (cont.)

CMS # /NQF #s Title

DM-15 / NQF 0729 Diabetes Composite (All or Nothing Scoring): Diabetes Mellitus: Hemoglobin A1c Control (< 8%)

DM-16 / NQF 0729 Diabetes Composite (All or Nothing Scoring): Diabetes Mellitus: Daily Aspirin or Antiplatelet Medication Use for Patients with Diabetes and Ischemic Vascular Disease

DM-17 / NQF 0729 Diabetes Composite (All or Nothing Scoring): Diabetes Mellitus: Tobacco Non-Use

HF-6 / NQF 0083 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

HTN-2 / NQF 0018 Controlling High Blood Pressure

IVD-1 / NQF 0075 Ischemic Vascular Disease (IVD): Complete Lipid Panel and Control

IVD-2 / NQF 0068 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

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22 Measures via GPRO Web Interface (cont.)

CMS # / NQF #s Title

PREV-5 / NQF N/A Breast Cancer Screening

PREV-6 / NQF 0034 Colorectal Cancer Screening

PREV-7 / NQF 0041 Preventive Care and Screening: Influenza Immunization

PREV-8 / NQF 0043 Pneumonia Vaccination Status for Older Adults

PREV-9 / NQF 0421 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

PREV-10 / NQF 0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

PREV-11 / NQF N/A Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

PREV-12 / NQF 0418 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

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PQRS GPRO Web Interface Reporting Requirements

• Group practices participating in PQRS GPRO must meet the following reporting requirements to satisfactorily report – Reporting requirements are based on the group practice’s size during

registration

Group Size Reporting Requirements

25-99 EPs Report on all measures included in the GPRO Web Interface; AND Populate data fields for the first 218 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample for each disease module or patient care measure. If the pool of eligible assigned beneficiaries is less than 218, then report on 100% of assigned beneficiaries. The group practice will also participate in CAHPS for PQRS if they select CMS-Certified Survey Vendor during registration.

100+ EPs Report on all measures included in the GPRO Web Interface; AND Populate data fields for the first 411 consecutively ranked and assigned beneficiaries in the order in which they appear in the group’s sample for each disease module or patient care measure. If the pool of eligible assigned beneficiaries is less than 411, then report on 100% of assigned beneficiaries; AND Report on all CAHPS for PQRS survey measures through a Certified Survey Vendor. Groups with 100+ EPs reporting via GPRO Web Interface will be required to also participate in CAHPS for PQRS.

ACO GPRO Web Interface Reporting Requirements

• For ACOs, GPRO Web Interface reporting criteria is as follows for all ACOs regardless of size: – Report on all measures included in the GPRO Web Interface; AND – Populate data fields for the first 411 consecutively ranked and

assigned beneficiaries in the order in which they appear in the ACO’s sample for each disease module or patient care measure

• If the pool of eligible assigned beneficiaries is less than 411, then report on 100% of assigned beneficiaries

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GPRO Web Interface Helpful Specifications and Documents

• Go to the GPRO Web Interface page of the CMS PQRS web site at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/GPRO_Web_Interface.html – Click on the link for the “2014 GPRO Web Interface Measures List, Narrative

Measure Specifications, and Release Notes” link to open the .zip file to access the following documents:

• The “2014 Group Practice Reporting Option (GPRO) Web Interface Disease Modules, Care Coordination/Patient Safety and Preventive Care Measures List” is a list of the (22) 2014 GPRO Web Interface measures.

• The “2014 Group Practice Reporting Option (GPRO) Web Interface Narrative Measure Specifications” provides a description of each of the 22 measures.

• The “2014 GPRO Web Interface Narrative Specification Release Notes” provides a list of changes to existing measures made since the release of the “2013 GPRO Narrative Measure Specifications”, Version 4.1.

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http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/GPRO_Web_Interface.html


GPRO Web Interface

CARE COORDINATION/PATIENT SAFETY (CARE) MODULE

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Care Coordination/Patient Safety (CARE) Module

• The Care Coordination/Patient Safety (CARE) Module contains two measures (sampled separately): – CARE-1: Medication Reconciliation – CARE-2: Falls: Screening for Future Fall Risk

• Patients are eligible for random sampling into either of the Patient Care Measures if – They have been assigned to the group practice – They are age 65 or older at the beginning of the measurement period* – For the Medication Reconciliation measure, they must have a hospital

discharge during the measurement year AND an office visit to the group practice within 30 days of the hospital discharge

* Patients may be removed from a measure within the module if a “CMS Approved Reason” has been granted OR if the patient’s date of birth has been modified in the GPRO Web Interface and they no longer meet the age criteria.

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CARE-1: Medication Reconciliation

Measure Description Percentage of patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented

GPRO Web Interface Data (XML or Manual Data Entry) Discharged from an inpatient facility during the measurement period?

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• Select this option if patient was not discharged from an inpatient facility No

• Select this option if patient was discharged from an inpatient facility on this date Yes

CARE-1: Medication Reconciliation (cont.)

GPRO Web Interface Data (XML or Manual Data Entry) Seen within 30 days following an inpatient facility discharge?

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• Select this option if the patient was not seen within 30 days following an inpatient facility discharge

No

• Select this option if the patient was seen within 30 days following an inpatient facility discharge - then Yes or No if reconciliation is documented

Yes


Guidance • This measure is reported for each discharge found for the

patient • The hospital care may have occurred under provider in a

group practice not participating in GPRO • The group practice must only answer the measure for those

discharges that are pre-populated into the WI during sampling • The group practice may verify the discharge date if evidence

of hospitalization or discharge is found in the record within 1-2 days of the pre-populated discharge date

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Guidance (cont.) • Acute care hospital discharges, psychiatric inpatient

discharges, skilled nursing facility discharges or rehabilitation inpatient discharges may be included in the denominator – Discharges are identified by one of four discharge day management

CPT codes for either hospital or nursing home discharges

• Satisfying the measure requires documentation that the clinician is aware of the inpatient facility discharge medications and will either keep the inpatient facility discharge medications or change the inpatient facility discharge medications or the dosage of inpatient facility discharge medications

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CARE-2: Falls: Screening for Future Fall Risk

Measure Description Percentage of patients aged 65 years and older who were screened for future fall risk at least once during the measurement period

GPRO Web Interface Data (XML or Manual Data Entry) Screened for future fall risk at least once during the measurement period?

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• Select this option if patient was not screened for future fall risk No

• Select this option if patient was screened for future fall risk Yes

• Select this option if future fall risk screening was not performed due to medical reasons

No Denominator Exception -

Medical Reasons

CARE-2: Falls: Screening for Future Fall Risk (cont.)

Guidance • This measure is reported for each patient in the measure

sample • Screening for future fall risk must include: Documentation of

no falls in the past year or only one fall without injury in the past year or documentation of two or more falls in the past year or any fall with injury in the past year

• There is a medical exception for this measure, for example, if the patient is not ambulatory, the medical exception may be utilized

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GPRO Web Interface

CORONARY ARTERY DISEASE (CAD) COMPOSITE MODULE

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Coronary Artery Disease (CAD) Composite Module

• The Coronary Artery Disease (CAD) Composite Module contains two component measures analyzed as an all or nothing composite: – CAD-2: Coronary Artery Disease (CAD): Lipid Control – CAD-7: Coronary Artery Disease (CAD): Angiotensin-

Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)

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Coronary Artery Disease (CAD) Composite Module (cont.)

• Patients are eligible for random sampling into the CAD Module if: – They have been assigned to the group practice – They are age 18 or older at the beginning of the measurement period* – They have a diagnosis of CAD (active or history of) anytime in the

medical record • A list of synonyms representing the diagnosis of CAD and clinical

codes sets can be found in the Supporting Documents for the CAD module

*Patients may be removed from the module if a “CMS Approved Reason” has been granted OR if the patient’s date of birth has been modified in the GPRO Web Interface and they no longer meet the age criteria.

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CAD-2: Coronary Artery Disease (CAD): Lipid Control

Measure Description Percentage of patients aged 18 years and older with a diagnosis of CAD seen within a 12 month period who have a LDL-C result < 100 mg/dL OR patients who have a LDL-C result ≥ 100 mg/dL and have a documented plan of care to achieve LDL-C < 100 mg/dL, including at a minimum the prescription of a statin GPRO Web Interface Data (XML or Manual Data Entry) Documented diagnosis of CAD (active or history of)?

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• Select this option if patient has a documented diagnosis of CAD Yes

• Select this option if unable to confirm the diagnosis of CAD for the patient

Not Confirmed - CAD

• Select this option if there is an “other” CMS-approved reason for patient disqualification from the module

No - Other CMS Approved Reason

CAD-2: Coronary Artery Disease (CAD): Lipid Control (cont.)

GPRO Web Interface Data (XML or Manual Data Entry) Is the patient’s LDL-C in range or appropriate plan of care (POC) in place for elevated LDL-C?

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• Select if the patient’s LDL-C is > 100 mg/dL and no POC documented OR LDL-C was not performed No

• Select if the patient’s LDL-C is <100 mg/dL OR > 100 with a documented POC (prescription of a statin at a minimum) Yes

• Select if the patient is not prescribed a statin medication for medical reasons

No - Denominator Exception -

Medical Reasons

• Select if the patient is not prescribed a statin medication for patient reasons

No - Denominator Exception - Patient

Reasons

• Select if the patient is not prescribed a statin medication for system reasons

No - Denominator Exception - System

Reasons

CAD-2: Coronary Artery Disease (CAD): Lipid Control (cont.)

Guidance: • An LDL-C result > 100 mg/dL needs to be accompanied by a current

prescription for a statin in order to pass the measure when the patient’s LDL-C is elevated (> 100) – A prescribed statin combination drug (i.e., lovastatin/niacin [Advicor]) meets

the requirements of this measure – Niacin alone does not meet the requirements of this measure

• A plan of care without statin therapy does not meet the requirements of this measure

• If the laboratory is unable to calculate an LDL-C value due to high triglycerides, select “No”

• If more than one LDL-C test is performed during the measurement period, use the result of the most recent test

• See CAD Drug Code tab in the Supporting Documents for list of lipid-lowering medications (list may not be all inclusive)

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CAD-7: Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes

or Left Ventricular Systolic Dysfunction (LVEF < 40%)

Measure Description Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy

GPRO Web Interface Data (XML or Manual Data Entry) Does the patient have LVSD (LVEF < 40% or documented as moderate or severe) OR has diabetes?

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• Select if the patient does not have LVSD or diabetes No

• Select if the patient has LVSD or diabetes Yes


or Left Ventricular Systolic Dysfunction (LVEF < 40%) (cont.)

GPRO Web Interface Data (XML or Manual Data Entry) If “Yes” to “has LVSD or diabetes”; then determine if patient is prescribed ACE inhibitor or ARB therapy.

Prescribed ACE inhibitor or ARB therapy at any time during the measurement period?

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• Select if the patient is not prescribed ACE inhibitor or ARB therapy No

• Select if the patient is prescribed ACE inhibitor or ARB therapy Yes

• Select if the patient is not prescribed ACE inhibitor or ARB therapy for medical reasons

No - Denominator Exception - Medical

Reasons

• Select if the patient is not prescribed ACE inhibitor or ARB therapy for patient reasons


Reasons

• Select if the patient is not prescribed ACE inhibitor or ARB therapy for system reasons


Reasons


or Left Ventricular Systolic Dysfunction (LVEF < 40%) (cont.)

• Guidance – If the patient has ever had an LVEF < 40% or a documented LVEF

as moderate or severe answer “Yes” to the presence of LVSD – A list of synonyms representing the LVSD and clinical codes sets

can be found in the Supporting Documents for the CAD module – If multiple diagnostic studies were performed on the same day

to measure ejection fraction, use the following hierarchy to determine if LVSD is present:

• cardiac catheterization • echocardiogram • MUGA or other cardiac scan • Prescribed may include prescription given to the patient for ACE

inhibitor or ARB therapy at one or more visits in the measurement period OR patient is already taking ACE inhibitor or ARB therapy as documented in the current medication list

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GPRO Web Interface

DIABETES MELLITUS (DM) MODULE (DM-2 AND COMPOSITE)

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Diabetes Mellitus (DM) Module

• The Diabetes Mellitus (DM) Module contains one measure and one composite measure made up of five component measures:

– DM-2: Percentage of patients aged 18 through 75 years with diabetes who had most recent hemoglobin A1c greater than 9.0%

– Optimal Diabetes Care (All or Nothing Scoring) • DM-13: Diabetes Mellitus: High Blood Pressure Control • DM-14: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control • DM-15: Diabetes Mellitus: Hemoglobin A1c Control (< 8%) • DM-16: Diabetes Mellitus: Daily Aspirin or Antiplatelet Medication

Use for Patients with Diabetes and Ischemic Vascular Disease • DM-17: Diabetes Mellitus: Tobacco Non-Use

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Diabetes Mellitus (DM) Module (cont.)

• Patients are eligible for random sampling into the Diabetes Module if – They have been assigned to the group practice – They are age 18 through 75 years of age at the beginning of the

measurement period* – They have a documented history of diabetes during the

measurement period or year prior to the measurement period


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Diabetes Mellitus (DM) Module (cont.)

GPRO Web Interface Data (XML or Manual Data Entry) History of DM?

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• Select if the patient does have a history of DM Yes

• Unable to confirm diagnosis of diabetes for the patient

Not Confirmed - DM



DM-2: Diabetes: Hemoglobin A1c Poor Control DM-15: Diabetes Mellitus: Hemoglobin A1c Control (< 8%)

Denominator Exclusions

DM-2 Measure Description Percentage of patients aged 18 through 75 years with diabetes who had most recent hemoglobin A1c greater than 9.0%

Denominator Exclusion – Patients who had gestational diabetes during the measurement period are excluded from the DM-2 measure

DM-15 Measure Description Percentage of patients 18 to 75 years of age with diabetes mellitus who had HbA1c greater than 8.0%

Denominator Exclusion – Patients who were pregnant or were permanent nursing home residents during the measurement period are excluded from the Optimal Diabetes Care Composite

Note: The exclusions for DM-2 and DM-15 are now different and have been updated for the program year 2014.

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GPRO Web Interface Data (XML or Manual Data Entry) Did the patient have one or more A1c tests documented in the measurement period?

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• Select if the patient does not have one or more A1c tests documented No

• Select if the patient does have one or more A1c tests documented - enter date of most recent test and value

Yes


Guidance • At a minimum, documentation in the medical record must include a

note indicating the date on which the HbA1c test was performed and the result

• Use the following priority ranking: – Lab report draw date – Lab report date – Flow sheet documentation – Practitioner notes – Other documentation

• If test was performed but result is not documented, record "0" (zero) value

• Use the DM Evaluation tab in the Supporting Document to find laboratory testing codes specific to this measure

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DM-13: Diabetes Mellitus: High Blood Pressure Control

Measure Description Percentage of patients ages 18 to 75 years of age with diabetes mellitus who had a blood pressure < 140/90 mmHg

GPRO Web Interface Data (XML or Manual Data Entry) Was the patient’s most recent blood pressure (BP) reading documented during the measurement period?

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• Select if the patient does not have a valid BP reading documented No

• Select if the patient’s most recent BP reading documented - enter date of most recent test, systolic and diastolic values

Yes

DM-13: Diabetes Mellitus: High Blood Pressure Control (cont.)

Guidance • Both the systolic and diastolic blood pressure measurements are required for

inclusion – If there are multiple BPs on the same date of service, use the lowest systolic and

lowest diastolic BP on that date as the representative BP

• Identify the most recent visit to the practitioner’s office or clinic that occurred during the measurement period in which a BP reading was noted

• To be eligible, the representative BP must have been obtained during a visit to the practitioner’s office or other non-emergency outpatient facility, such as a clinic or urgent care center

– Outpatient visits for the sole purpose of having a diagnostic test or surgical procedure performed (e.g., stress test, endoscopy, or IV contrast radiology procedures) are not eligible

• Home BP monitor readings may not be used

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DM-14: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control

Measure Description Percentage of patients ages 18 to 75 years with diabetes mellitus who had LDL-C < 100 mg/dL

GPRO Web Interface Data (XML or Manual Data Entry) Did the patient have one or more LDL-C tests performed in the measurement period?

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• Select if the patient does not have one or more LDL-C tests documented No

• Select if the patient does have one or more LDL-C tests documented - enter date of most recent test, and value

Yes

DM-14: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control (cont.)

Guidance • At a minimum, documentation in the medical record must include a note

indicating the date on which the LDL-C test was performed and the result documented

• If test was performed but result is not documented, record a "0" (zero) value • Use the following priority ranking:

– Lab report draw date – Lab report date – Flow sheet documentation – Practitioner notes – Other documentation

• If laboratory unable to calculate LDL-C value due to high triglycerides, record “0” (zero)

– If the test result is labeled "unreliable" and a result is provided, also record “0” (zero) – Do not enter a ratio as a value (it is not a valid value)

• A calculated LDL may be used for LDL-C screening and control indicators 41

DM-16: Diabetes Mellitus: Daily Aspirin or Antiplatelet Medication Use for Patients with Diabetes and Ischemic

Vascular Disease

Measure Description Percentage of patients ages 18 to 75 years of age with diabetes mellitus and ischemic vascular disease with documented daily aspirin or antiplatelet medication use during the measurement year unless contraindicated

GPRO Web Interface Data (XML or Manual Data Entry) History of Ischemic Vascular Disease (IVD)?

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• Select if the patient does not have a history of IVD No

• Select if the patient does have a history of IVD Yes


Vascular Disease

Measure Description Percentage of patients ages 18 to 75 years of age with diabetes mellitus and ischemic vascular disease with documented daily aspirin or antiplatelet medication use during the measurement year unless contraindicated

GPRO Web Interface Data (XML or Manual Data Entry) Taking Aspirin or Antiplatelet Medication?

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• Select if the patient is not taking aspirin or antiplatelet medication No

• Select if the patient is taking aspirin or antiplatelet medication Yes

• Select if the patient is not taking aspirin or an antiplatelet medication for medical reasons

No – Denominator Exception - Medical

Reasons


Vascular Disease (cont.)

Guidance • The coding supplied by the measure owners to identify ischemic vascular disease

(IVD) is not the same in the IVD module as it is for this component measure (DM-16). The DM-16 list does not include cardiac surgery procedure codes. In addition, the Drug Codes may differ, as these measures have different measure owners.

• Accepted contraindications: – Anticoagulant use or Coumadin (Warfarin) – Any history of gastrointestinal (GI) or intracranial bleed (ICB) – Allergy to aspirin (ASA)

• Gastroesophageal reflux disease (GERD) is not automatically considered a contraindication but may be included if specifically documented as a contraindication by the physician

• The following may be exclusions if specifically documented by the physician: – Use of non-steroidal anti-inflammatory agents – Documented risk for drug interaction – Uncontrolled hypertension defined as > 180 systolic, > 110 diastolic – Other provider documented reason for not being on ASA therapy

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DM-17: Diabetes Mellitus: Tobacco Non-Use

Measure Description Percentage of patients ages 18 to 75 years of age with a diagnosis of diabetes who indicated they were tobacco non-users

GPRO Web Interface Data (XML or Manual Data Entry) Was the patient screened and identified as a tobacco non-user during the measurement period?

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• Select if the patient was screened and identified as a tobacco user No

• Select if the patient was screened and identified as a tobacco non-user Yes

• Select if the patient was not screened for tobacco use

Not Screened/Unknown

GPRO Web Interface

HEART FAILURE (HF) MODULE

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Heart Failure (HF) Module

• The Heart Failure (HF) Module contains one measure: – HF-6: Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic

Dysfunction (LVSD)

• Patients are eligible for random sampling into the HF Module if: – They have been assigned to the group practice – They are age 18 or older at the beginning of the measurement period*

– The patient has a documented diagnosis of HF (active or history of) at anytime in the patient’s history up through the last day of the measurement period


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Heart Failure (HF) Module (cont.)

GPRO Web Interface Data (XML or Manual Data Entry) Documented diagnosis or history of HF?

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• Select this option if the patient has an active diagnosis or documented history of HF anywhere in the medical record

Yes

• Select this option if you are unable to confirm the diagnosis of HF for the patient Not Confirmed - HF

• Select this option if there is an "other" CMS-approved reason for patient disqualification from the module


HF-6: Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Measure Description Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge

GPRO Web Interface Data (XML or Manual Data Entry) Does the patient have LVSD (LVEF <40% or documented as moderate or severe)?

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• Select this option if the patient does not have LVSD No

• Select if the patient has LVSD Yes

HF-6: Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) (cont.)

Was the patient prescribed a beta-blocker therapy at any time during the measurement period?

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• Select if the patient is not prescribed beta-blocker therapy No

• Select if the patient is prescribed beta-blocker therapy Yes

• Select if the patient is not prescribed beta-blocker therapy for medical reasons


Reasons

• Select if the patient is not prescribed beta-blocker therapy for patient reasons


Reasons

• Select if the patient is not prescribed beta-blocker therapy for system reasons


Reasons


Guidance • If the patient has ever had an LVEF < 40% or a documented LVEF as

moderate or severe answer “Yes” to the presence of LVSD • A list of synonyms representing heart failure, LVSD, beta-blocker

medications lists and clinical codes sets can be found in the Supporting Documents for the HF module

• Bisoprolol, carvedilol, or sustained release metoprolol succinate are the ONLY beta-blockers allowed for this measure

• If multiple diagnostic studies were performed on the same day to measure ejection fraction, use the following hierarchy to determine if LVSD is present: − cardiac catheterization − echocardiogram − MUGA or other cardiac scan

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Guidance • Prescribed Outpatient Setting may include prescription given to the

patient for beta-blocker therapy at one or more visits in the measurement period OR patient already taking beta-blocker therapy as documented in the current medication list

• Prescribed Inpatient Setting may include prescription given to the patient for beta-blocker therapy at discharge OR beta-blocker therapy to be continued after discharge as documented in the medication list

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GPRO Web Interface

HYPERTENSION (HTN) MODULE

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Hypertension (HTN) Module

• The Hypertension (HTN) Module contains one measure: – HTN-2: Controlling High Blood Pressure

• Patients are eligible for random sampling into the HTN Module if – They have been assigned to the group practice – They are age 18 through 85 at the beginning of the measurement

period* – They have a diagnosis of HTN


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Hypertension (HTN) Module (cont.)

GPRO Web Interface Data (XML or Manual Data Entry) History of HTN?

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• Select if the patient does have a history of HTN Yes

• Select if the patient does not have a history of HTN

Not Confirmed - HTN

• Select this option if there is a denominator exclusion for patient disqualification from the module

Denominator Exclusion


Other CMS Approved Reason

HTN-2: Controlling High Blood Pressure

Measure Description Percentage of patients aged 18 through 85 years of age who had a diagnosis of HTN and whose blood pressure (BP) was adequately controlled (< 140/90 mmHg) during the measurement year

GPRO Web Interface Data (XML or Manual Data Entry) Most recent BP taken during the measurement period?

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• Select if the patient’s most recent BP measurement was not taken during the measurement period

No

• Select if the patient’s most recent BP measurement was taken during the measurement period – enter date of BP, systolic and diastolic values

Yes

GPRO Web Interface

ISCHEMIC VASCULAR DISEASE (IVD) MODULE

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Ischemic Vascular Disease (IVD) Module

• The Ischemic Vascular Disease (IVD) Module contains two measures: – IVD-1: Ischemic Vascular Disease (IVD): Complete Lipid Panel and Control – IVD-2: Ischemic Vascular Disease (IVD): Use of Aspirin or Another

Antithrombotic

• Patients are eligible for random sampling into the IVD Module if – They have been assigned to the group practice – They are age 18 or older at the beginning of the measurement period* – They have a diagnosis of ischemic vascular disease


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Ischemic Vascular Disease (IVD) Module (cont.)

GPRO Web Interface Data (XML or Manual Data Entry) History of IVD?

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• Select this option if the patient has a documented history of IVD or was discharged alive for AMI, CABG or PCI anywhere in the medical record

Yes

• Select if the patient does not have a history of IVD or was not discharged alive for AMI, CABG or PCI anywhere in the medical record

Not Confirmed - IVD


Other CMS Approved Reason

IVD-1: Ischemic Vascular Disease (IVD): Complete Lipid Panel LDL Control

Measure Description Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of IVD during the measurement period, and who had a complete lipid profile performed during the measurement period and whose LDL-C was adequately controlled (< 100 mg/dL)

GPRO Web Interface Data (XML or Manual Data Entry) At least one lipid profile (or ALL component tests) during the measurement period?

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• Select if the patient’s most recent lipid profile was not taken during the measurement period

No

• Select if the patient’s most recent lipid profile was taken during the measurement period – enter date of most recent test and value

Yes

IVD-1: Ischemic Vascular Disease (IVD): Complete Lipid Panel LDL Control (cont.)

Guidance • If laboratory unable to calculate LDL-C value due to high triglycerides, record

“0” (zero)

– If the test result is labeled "unreliable" and a result is provided, also record “0” (zero)

– Do not enter a ratio as a value (it is not a valid value)

• If LDL-C could not be calculated due to high triglycerides, count direct result as this component of the complete lipid profile

• Use the IVD Evaluation tab in the Supporting Document to find laboratory testing codes specific to this measure

• There are no medical exceptions for this measure

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IVD-2: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

Measure Description Percentage of patients aged 18 years and older with Ischemic Vascular Disease (IVD) with documented use of aspirin or another antithrombotic

GPRO Web Interface Data (XML or Manual Data Entry) Documented use of aspirin or another antithrombotic during the measurement period?

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• Select this option if the patient does not use aspirin or another antithrombotic No

• Select this option if the patient uses aspirin or another antithrombotic Yes

IVD-2: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic (cont.)

Guidance • Oral antithrombotic therapy includes: Aspirin, clopidogrel or combination of

aspirin and extended release dipyridamole, Prasugrel, Ticagrelor, and Ticlopidine

• Use the IVD Drug Codes tab in the Supporting Document to find aspirin or other antithrombotic codes specific to this measure

• There are no medical exceptions for this measure

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GPRO Web Interface

PREVENTIVE CARE (PREV) MODULE

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Preventive Care (PREV) Module

• There are eight preventive care (PREV) measures*: – PREV-5: Breast Cancer Screening – PREV-6: Colorectal Cancer Screening – PREV-7: Preventive Care and Screening: Influenza Immunization – PREV-8: Pneumonia Vaccination Status for Older Adults – PREV-9: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up – PREV-10: Preventive Care and Screening: Tobacco Use: Screening and Cessation

Intervention – PREV-11: Preventive Care and Screening: Screening for High Blood Pressure and Follow-

Up Documented – PREV-12: Preventive Care and Screening: Screening for Clinical Depression and Follow-

Up Plan

• Each preventive care measure is sampled separately

* Patients may be removed from a measure within the module if a “CMS Approved Reason” has been granted OR if the patient’s date of birth has been modified in the GPRO Web Interface and they no longer meet the age criteria.

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PREV-5: Breast Cancer Screening

Measure Description Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer within 27 months • Patients are eligible for random sampling into the PREV-5 measure if:

– They have been assigned to the group practice – They are female and age 50 through 74 at the beginning of the

measurement period • Patient may be removed from the measure if a denominator exclusion is

applicable for patient disqualification from the module • Patients may be removed from the measure if the gender is updated from

female in the patient’s demographics data

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PREV-5: Breast Cancer Screening (cont.)

GPRO Web Interface Data (XML or Manual Data Entry) Breast cancer screening performed during the measurement period or within 27 months prior to the measurement period end date?

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• Select if the patient was not screened for breast cancer No

• Select if the patient was screened for breast cancer Yes

Guidance • Denominator exclusions are defined as evidence of two separate

mastectomies or bilateral mastectomies occurring by the end of the measurement period

• Screening includes breast imaging, breast x-ray, diagnostic mammography, digital mammography, mammogram, screening mammography

• Use the Evaluation and Exclusions/Exceptions tabs in the Supporting Document to find codes specific to this measure

PREV-6: Colorectal Cancer Screening

Measure Description Percentage of patients aged 50 through 75 years who received the appropriate colorectal cancer screening

• Patients are eligible for random sampling into the PREV-6 measure if: – They have been assigned to the group practice – They are age 50 through 75 years at the beginning of the

measurement period • Patient may be removed from the measure if a denominator exclusion is

applicable for patient disqualification from the module

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PREV-6: Colorectal Cancer Screening (cont.)

GPRO Web Interface Data (XML or Manual Data Entry) Colorectal cancer screening is current during the measurement period?

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• Select this option if colorectal cancer screening is not current No

• Select this option if colorectal cancer screening is current Yes

PREV-6: Colorectal Cancer Screening (cont.)

Guidance • Note: Current colorectal cancer screening is defined as performing fecal occult

blood test (FOBT) within 12 months, flexible sigmoidoscopy during the reporting period or the four years prior to the reporting period, or colonoscopy during the reporting period or the nine years prior to the reporting period

• FOBT includes ColoCARE, Coloscreen, EZ Detect, Fecal occult blood test, flushable reagent pads, flushable reagent stool blood test, guaiac smear test, Hemoccult, Seracult, stool occult blood test, FIT

• Colorectal screening does not include: virtual colonoscopy, Barium enema, or Colovantage

• Patient refusal is not a reason to exclude • Denominator exclusions include: Diagnosis or past history of total colectomy

or colorectal cancer – refer to Supporting Document tabs

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PREV-7: Preventive Care and Screening: Influenza Immunization

Measure Description Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

• Patients are eligible for random sampling into the PREV-7 measure if: – They have been assigned to the group practice – They are age 6 months or older at the beginning of the measurement

period – They were seen for a visit between October 1, 2013 and March 31,

2014

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PREV-7: Preventive Care and Screening: Influenza Immunization (cont.)

GPRO Web Interface Data (XML or Manual Data Entry) Was the patient seen for an office visit between October 1, 2013 and March 31, 2014 and received an influenza immunization OR reported receipt of an influenza immunization?

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• Select this option if the patient did not receive an influenza immunization No

• Select this option if the patient received an influenza immunization or reported previous receipt Yes

• Select this option if the patient did not receive an influenza immunization for medical reasons


Reasons

• Select this option if the patient did not receive an influenza immunization for patient reasons

No – Denominator Exception - Patient

Reasons

• Select this option if the patient did not receive an influenza immunization for system reasons

No – Denominator Exception – System

Reasons

PREV-7: Preventive Care and Screening: Influenza Immunization (cont.)

Guidance • Previous receipt is defined as receipt of the current season’s influenza

immunization from another provider OR from same provider prior to the visit to which the measure is applied (typically, prior vaccination would include influenza vaccine given since August 1, 2013)

• Patients are not sampled into the measure unless a primary care office visit was found attributed to the group practice between October 1, 2013 and March 31, 2014

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PREV-8: Pneumonia Vaccination Status for Older Adults

Measure Description Percentage of patients aged 65 years and older who have ever received a pneumococcal vaccine

• Patients are eligible for random sampling into the PREV-8 measure if: – They have been assigned to the group practice – They are age 65 years or older at the beginning of the measurement

period

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PREV-8: Pneumonia Vaccination Status for Older Adults (cont.)

GPRO Web Interface Data (XML or Manual Data Entry) Has patient ever received a pneumococcal vaccination?

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• Select this option if the patient has never received a pneumococcal vaccination No

• Select this option if the patient has ever received a pneumococcal vaccination Yes

Guidance • Refer to the Supporting Document Evaluation, Exclusions/Exceptions and

Drug tabs for coding for this measure

PREV-9: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

Measure Description • Percentage of patients aged 18 years and older with a documented BMI

during the encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter

Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30 Age 18 – 64 years BMI ≥ 18.5 and < 25 • Patients are eligible for random sampling into the PREV-9 measure if

– They have been assigned to the group practice – They are age 18 years or older at the beginning of the measurement

period • Patient may be removed from the measure if a denominator exclusion is


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(cont.) GPRO Web Interface Data (XML or Manual Data Entry) BMI calculated within the past six months or during the current visit?

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• Select this option if the patient has not had a BMI calculated No

• Select this option if the patient has had a BMI calculated Yes

• Select this option if the BMI measurement was not performed for medical reasons

No - Denominator Exception -

Medical Reasons

• Select this option if the BMI measurement was not performed for patient reasons


Reasons


(cont.) GPRO Web Interface Data (XML or Manual Data Entry) Most recent BMI is within normal parameters?

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• Select this option if the most recent BMI is outside of normal parameters No

• Select this option if the most recent BMI is within normal parameters Yes

• Select this option if there was no follow-up plan documented No

• Select this option if there was a follow-up plan documented Yes

Was a follow-up plan documented if the BMI is outside of normal parameters?


(cont.)

Guidance • Body mass index (BMI) expressed as weight/height (BMI; kg/m2), is

commonly used to classify weight categories • Calculated BMI requires an eligible professional or their staff to measure

both the height and weight. Self-reported values cannot be used. BMI is calculated either as weight in pounds divided by height in inches squared multiplied by 703, or as weight in kilograms divided by height in meters squared

• Medical Reasons may include patient is pregnant, patient is receiving palliative care, or patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status

• Patient Reasons may include patient refuses BMI measurement or if there is any other reason documented in the medical record by the provider explaining why BMI measurement was not appropriate

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(cont.)

Guidance • Follow-up may include, but is not limited to: documentation of

education, referral (such as, a registered dietician, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon), pharmacological interventions or dietary supplements, exercise counseling or nutrition counseling

• Follow-up plan is not required for normal BMI • Refer to the Supporting Document Evaluation, Exclusions and Drug

tabs for coding for this measure

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PREV-10: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Measure Description • Percentage of patients aged 18 years and older who were screened for

tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user – Patients are eligible for random sampling into the PREV-10 measure if:

• They have been assigned to the group practice • They are age 18 years or older at the beginning of the measurement

period

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PREV-10: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

(cont.) GPRO Web Interface Data (XML or Manual Data Entry) Was the patient screened for tobacco use at least once within 24 months and identified as a tobacco user?

82

• Select if the patient was screened for tobacco use and identified as a tobacco non-user No

• Select if the patient was screened for tobacco use and identified as a tobacco user Yes

• Select if the patient was not screened for tobacco use Not Screened/Unknown

• Select if the patient was not screened for tobacco use for medical reasons


Reasons

PREV-10: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (cont.)

GPRO Web Interface Data (XML or Manual Data Entry) If “Yes”, did the patient receive tobacco cessation intervention?

83

• Select if the patient did not receive tobacco cessation intervention No

• Select if the patient did receive tobacco cessation intervention Yes

Guidance • Tobacco use may include any type of tobacco: tobacco smoking,

cigarette/tobacco/pipe smoking/smoker, cigarette dependence, tobacco use disorder, chew tobacco, smokeless tobacco, snuff

• Within 24 months is defined as the 24-month look-back period of time from the measurement period end date (1/1/2013 – 12/31/2014)

• If there is more than 1 patient query regarding tobacco use, use the most recent • Cessation counseling includes brief counseling (3 minutes or less), and/or

pharmacotherapy • Refer to the Drug Code tab in the PREV Supporting Document for list of tobacco

cessation agents

PREV-11: Screening for High Blood Pressure and Follow-Up Documented

Measure Description Percentage of patients aged 18 years and older seen during the measurement

period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure reading as indicated

• Patients are eligible for random sampling into the PREV-11 measure if – They have been assigned to the group practice – They are age 18 years or older at the beginning of the measurement



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PREV-11: Screening for High Blood Pressure and Follow-Up Documented (cont.)

GPRO Web Interface Data (XML or Manual Data Entry) Screened for high blood pressure (BP) using the most recent BP

85

• Select if the patient was not screened for high blood pressure No

• Select if the patient was screened for high blood pressure Yes

• Select if the patient was not screened for high blood pressure for medical reasons


Reasons

• Select if the patient was not screened for high blood pressure for patient reasons

No - Denominator Exception - Patient Reasons


GPRO Web Interface Data (XML or Manual Data Entry) Was most recent BP within normal parameters?

86

• Select if the recommended follow-up plan was not documented based on the most recent blood pressure reading

No

• Select if the recommended follow-up plan was documented based on the most recent blood pressure reading

Yes

• Select if the patient’s blood pressure was not within normal parameters No

• Select if the patient’s blood pressure was within normal parameters Yes

If patient’s most recent blood pressure was not within normal parameters was a recommended follow-up plan documented?


Guidance • Patients with a Medicare claim indicating a history of hypertension prior to the first

day of the measurement period (1/1/2014) will not be included in your sample for this measure

• A normal blood pressure reading (<120 systolic and < 80 diastolic) requires no documentation of follow-up

• Recommended follow-up based on BP classification includes: recommending screening interval follow-up, lifestyle modifications, referrals to alternative/primary care provider, anti-hypertensive pharmacological therapy, laboratory tests, or an electrocardiogram

• Need to link the recommended follow-up to the elevated blood pressure using guidance provided

• Pre-hypertensive BP reading, First hypertensive BP reading and Second hypertensive BP reading are defined and appropriate follow-up noted for each in the Narrative Specifications and Data Guidance provided

• Recommended follow-up has been explained in much more detail. This information is in both the Narrative Specifications and Data Guidance

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PREV-12: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Measure Description Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen • Patients are eligible for random sampling into the PREV-12 measure if:

– They have been assigned to the group practice – They are age 12 years or older at the beginning of the measurement



88

PREV-12: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (cont.)

GPRO Web Interface Data (XML or Manual Data Entry) Was patient screened for clinical depression using an age appropriate standardized tool during the measurement period?

89

• Select this option if the patient was not screened for clinical depression using a standardized tool No

• Select this option if the patient was documented as having been screened for clinical depression using one of the standardized tools

Yes

• Select this option if the patient was not screened for clinical depression using a standardized tool due to a medical reason


Reasons

• Select this option if the patient was not screened for clinical depression using a standardized tool due to a patient reason


Reasons


GPRO Web Interface Data (XML or Manual Data Entry) If the patient was screened, was the screen positive?

90

• Select this option if the patient's screen was not positive for clinical depression No

• Select this option if the patient's screen was positive for clinical depression Yes

• Select this option if a follow-up plan for depression is not documented No

• Select this option if a follow-up plan for depression is documented Yes

If the screen was positive for clinical depression, was a follow-up plan for depression documented during the measurement period?


Guidance • Screening includes completion of a clinical or diagnostic tool used to

identify people at risk of developing or having a certain disease or condition even in the absence of symptoms

• This measure requires the screening to be completed in the office of the provider filing the code

• Follow-up plan may include a proposed outline of treatment to be conducted as a result of positive clinical depression screening

• Follow-up for a positive depression screening must include one (1) or more of the following: Additional evaluation, Suicide Risk Assessment, Referral to a practitioner who is qualified to diagnose and treat depression, Pharmacological interventions, or other interventions or follow-up for the diagnosis or treatment of depression

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Guidance • Use a normalized and validated depression screening tool developed

for the patient population where it is being utilized. Examples of depression screening tools include but are not limited to:

− Adolescent Screening Tools (12-17 years) − Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression

Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire, Center for Epidemiologic Studies Depression Scale (CES-D) and PRIME MD-PHQ-2

• Refer to the Supporting Document Evaluation, Exclusions and Drug tabs for coding for this measure

• Although the patient may have access to the depression screening tool in advance of the appointment, the depression screening results must be documented on the date of the encounter (date of appointment). The results must be reviewed/verified and documented by the eligible professional in the medical record on the date of the encounter to meet the screening portion of this measure

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GPRO Web Interface

RESOURCES

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Abbreviations

• ACO – Accountable Care Organization • CAD – Coronary Artery Disease • CARE – Care Coordination/Patient Safety • DM – Diabetes Mellitus • EP – Eligible professional • GPRO – Group Practice Reporting Option • HF – Heart Failure • HTN – Hypertension • IVD – Ischemic Vascular Disease • PQRS – Physician Quality Reporting System • PREV – Preventive Care

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Resources/Where to Begin

• GPRO Web Interface web page: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/GPRO_Web_Interface.html

• CMS Frequently Asked Questions (FAQs): https://questions.cms.gov/

• QualityNet Help Desk – Monday – Friday: 7:00 am - 7:00 pm CT – E-mail: [email protected] – Phone: (866) 288-8912 (TTY 1-877-715-6222) – Fax: (888) 329-7377

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https://questions.cms.gov/

mailto:[email protected]